Woman With Neck Pain and Swelling

Article Outline

• Diagnosis
  • Superior vena cava syndrome
• References
• Copyright

[Ann Emerg Med. 2010;56:305.]

A 43-year-old woman presented to the emergency department with several weeks of neck pain and swelling, low energy, cold intolerance, and unintentional weight loss. Medical history was unremarkable. Physical examination results were notable for a large anterior neck mass, facial fullness, and distended superficial veins on the chest wall (Figure 1, arrow). Chest radiography revealed a superior mediastinum mass (Figure 2, arrow). Chest computed tomography with intravenous contrast demonstrated abnormal signal in the right side of the anterior chest (Figure 3, arrow).

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• Figure 1. 

  Large anterior neck mass, facial fullness, and distended superficial veins on the chest wall (arrow).

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• Figure 2. 

  Superior mediastinum mass (arrow).

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• Figure 3. 

  Chest computed tomography with intravenous contrast in the right side of the anterior chest (arrow).

Used with permission of Jonathan Rosenson, MD, Department of Emergency Medicine, Alamda County Medical Center/Highland Hospital, Oakland, CA.

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Diagnosis 

Superior vena cava syndrome 

The patient had a large substernal thyroid mass compressing the superior vena cava and right subclavian vein. Intravenous contrast is observed in the collateral veins on the right side of the chest wall on chest computed tomography (Figure 3). First described in 1757, superior vena cava syndrome results from internal or external obstruction of venous return through the superior vena cava.¹ Before widespread use of antibiotics, infections such as syphilitic aortic aneurysm and infectious complications such as fibrosing mediastinitis were frequent causes of the superior vena cava syndrome.² In the past 50 years, malignancies such as non–small-cell and small-cell lung cancer, lymphoma, thymoma, and metastatic lesions have accounted for the majority of cases of superior vena cava syndrome.³ Nonmalignant causes of superior vena cava syndrome include superior vena cava thrombosis from intravascular devices or teratoma and, as in this case, thyroid masses. Treatment is aimed at debulking the obstructing lesion and treating the underlying disease process.⁴ This patient underwent total thyroidectomy, with subsequent resolution of her symptoms.

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References 

1. Parish JM, Marschke RF, Dines DE, et al. Etiologic considerations in superior vena cava syndrome. Mayo Clin Proc. 1981;56:407–413
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2. Schechter MM. The superior vena cava syndrome. Am J Med Sci. 1954;227:46–56
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3. Wilson LD, Detterbeck FC, Yahalom J. Superior vena cava syndrome with malignant causes. N Engl J Med. 2007;356:1862–1870
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4. In:  Goldman L,  Ausiello D editor. Cecil Textbook of Medicine. Philadelphia, PA: Saunders; 2004;
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